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Federal Property:<br />
Impact Aid Program Source Check Form Extract<br />
The survey date is December 11, 2007.<br />
CA003063 Address: 656 53RD ST<br />
(1) (2) (3) (4) (5) (6) (7) (8)<br />
Parent/Guardian's Parent/Guardian's Branch of Service Parent/Guardian Parent/Guardian Name of Pupil Living Wilh Pupil's Pupil's<br />
Name Address (<strong>In</strong>cluding rank, <strong>In</strong> Column (1) <strong>In</strong> Column (1) Parent/Guardian in Date of Grade<br />
If applicable) lived on worked on Column (1) Birth<br />
or above property above property<br />
Foreign Mllilary as of as of<br />
Government survey dale survey dale<br />
YES I NO YES I NO<br />
ALiCHIA CLAYTON 873 32nd SI #1 X Alicia Carter 2/18/1998 4<br />
ALiCHIA EDWARDS 873 32nd SI #1 X Damesha Carter 2/18/1998 4<br />
Juan Carios/Hortensla Caslillo 950 40th SI #4 X Juan Castillo 5/4/1991 10<br />
Hephzibah Cornish 656 53rd St #6 X Hezzekiah Coleman 4/26/2001 1<br />
Hephzibah Cornish 656 53rd sl #6 X Nehemiah Coleman 10/31/2002 0<br />
RHONDA WYNNE 3217Wes1SI#1 X QUincy Cotton 6/19/1992 9<br />
CECILIA SMITH 4520 MONTGOMERY ST #4 X Malik Couey 10/1/1990 12<br />
Alichia Clayton 873 32ND ST #1 X Miccle Edwards 11/21/1990 10<br />
Evans, Aleta 3217 West St #3 X Alexandra Evans 7/5/1999 3<br />
DELONDA DAWKINS 987 63rd St #2 X Aaron Frison 8/8/1993 9<br />
Ermelinda Godinez! Paolo Orteg 873 32nd St #4 X Berenice Godinez 1111/2002 0<br />
SABRINA GREEN 656 53RD ST#14 X Nikita Green 3/1/1990 12<br />
KEVIN TROTIER, FATHER 656 53RD ST #5 X Aujihnae Harris 5/16/1997 5<br />
Reatha LoWSIMOYA SURRELL 594 63rd St #2 X Shree Harris 2/9/1995 7<br />
This is 10 certify Ihallhe <strong>In</strong>formallon shown under columns (4) and (5)<br />
olthe foregoing sheel(s) is correcllor Ihe person Iisled under Column (1)<br />
on the survey date.<br />
This is 10 certify Ihallhe <strong>In</strong>formallon shown under columns (4) and (5)<br />
of Ihe foregoing sheel(s) Is correct for Ihe person IIsled under Column (1)<br />
on the survey date.<br />
Signature Dale Signalure Dale<br />
Tille Agency Tille<br />
School District<br />
This <strong>In</strong>formalion is Ihe basis for paymenllo Ihls school dlslrlct of federal funds under Ihe Impact Aid Program (TIlle VIII of Ihe Elemenlary and Secondary Educallon Acl).<br />
This form musl be signed and daled for Ihls school dlslrlct 10 receive furids based on this <strong>In</strong>formalion.
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